The Ebola Inferno: A Review of Dr. Hatch's Memoir

I just finished another Ebola memoir by an American doctor who battled the virus during the West African outbreak. Inferno: A Doctor's Ebola Story by UMass's Dr. Steven Hatch is much more than patient vignettes and is really an intimate window into how an academic infectious disease physician fared against a deadly virus. 

Dr. Hatch's book moves from his first pre-Ebola visit to Liberia in which he was tasked with building medical capacity in a country ravaged by a recent civil war to his return to the country in the midst of the Ebola outbreak.

It is now almost cliche to say that the usual measures didn't work in Liberia because of the populace's distrust of the government and that one-size-fits-all solutions don't exist. Dr. Hatch unpacks that statement by weaving into this narrative an important discussion of the origins of Liberia and the civil war. As Dr. Hatch demonstrates, both of these factors distinctly shaped the response to the virus as did the Christianity and animistic beliefs of the population. 

Another aspect of the book that bears highlighting is Dr. Hatch's unfortunate navigation of the myriad details regarding his return to the panic-stricken US and the inanity of bureaucracies that were responsive less to science than to pandering politicians. 

I highly recommend the book.

Face to Face with Ebola: A Review of Dr. Kent Brantly's Memoir

Remembering the height of the worldwide Ebola pandemonium in 2014 is instructive 3 year later. All the names, dates, controversies and places from that era have long faded from headlines and the memories of the general public. Even I, who was keeping up with Ebola on an almost minute-by-minute basis, sometimes forget the intensity of the outbreak and continual media coverage. 

One of the first explosions of worldwide media occurred, of course, with the infection of American family medicine physician and medical missionary Dr. Brantly in Liberia. His infection, his transport back to the US, and his receipt of experimental therapeutics were unprecedented in the history of Ebola. The opposition to his transport to Atlanta was also unprecedented, disturbing, and shocking. 

I was one of those who vociferously argued for Dr. Brantly's evacuation to the US where he received state-of-the art treatment and recovered. Because of those efforts I made in the media at the time I was honored to be in the same room with him during a White House event. But I had no real familiarity with his personal experiences in Liberia and with Ebola.

I recently read Dr. Brantly and his wife's memoir of the experience Called for Life: How Loving Our Neighbor Led us into the Heart of the Ebola Epidemic. This book, written in 2015, is not only a gripping and poignant account of the Brantlys experiences with the outbreak but also how they coped with Dr. Brantly's infection.

The book weaves together the Brantly's decisions to enter the medical field and the career choices they made with the narrative of the Ebola outbreak. Many of the observations included are, by now, familiar (e.g. the unique challenges of containing Ebola in an urban populated area that emerged from civil war, the angry mobs, and the overall logistical challenges. However, to me, the value of the book is chiefly Dr. Brantly's recounted of his own personal experience with Ebola.

A few important points he makes merit emphasis:

• The initial negative Ebola test which required repeating given lack of sensitivity at early infection
• The necessity of ruling out malaria and initially treating for malaria empirically
• The voluminous diarrhea and ensuing electrolyte abnormalities of Ebola and the absoulte need to correct them
• The role of experimental agents and the challenges with administering them in a resource-challenged environment 

My favorite part of the book is Dr. Brantly's recounting of the  appearance of a top Ebola virologist outside his window in Liberia to discuss experimental treatments with him. 

Reading this family physician's account of his successful battle with the deadly Ebola virus is well worth it.

Ebola Back in the DRC: An Opportunity for New Tools to be Tried

The latest appearance of the Ebola virus, which has caused approximately 30 identified outbreaks in humans since it was first recognized in 1976, will provide an opportunity to gauge how outbreak response has improved over the past 3 years. That this outbreak is occurring in the DRC, a nation relatively adept at managing the virus, will likely lead to its rapid extinguishment. Thus far, there are 11 suspected cases and 3 deaths in the remote area of the DRC where the disease has reappeared. The index case has secondarily (and fatally) infected one of his caregivers and his taxi driver. Contacts are under surveillance and thus far one has tested positive (and there is some concern that all suspect cases are not truly Ebola).

In recent years, in the wake of the horrific 2014 West African Ebola outbreak, new tools and strategies have been formulated and refined including a vaccine, a concept-of-operations for vaccination, and enhanced supportive care (not to mention the rapid involvement of WHO for technical assistance). 

In the coming days, as the outbreak unfolds and case numbers change it will be important to see if, in addition to the tried-and-true measures of case finding, isolation, and body fluid protection, the Merck vaccine (or others) is used to accelerate the control of this outbreak. Currently, a GAVI stockpile of 300,000 doses of the Merck vaccine stands at the ready.

Emerging infectious diseases, exemplified by Ebola, will continue to plague the human race and it is only by continually improving our response efforts through science and preparedness that they can be beaten back.

Corruption in the Time of Ebola: A Review of Amy Maxmen's Ebola's Unpaid Heroes

Though Ebola has largely slipped from the headlines in favor of Zika, the infectious disease du jour, there is still much to learn from history's largest outbreak of this deadly disease. Currently, all three of the major countries that the virus ravaged are free from transmission and it will be vitally important for their surveillance systems to be vigilant for any recrudescence that may occur.

Several books have been written on the outbreak by now and I am sure many more will be written. The latest that I have read is a small book by Newsweek's Amy Maxmen entitled Ebola's unpaid heroes: How billions in aid skipped those at the frontline.

In this book Maxmen takes the reader through the experience of healthcare workers dealing with Ebola in Sierra Leone. In the midst of widespread death, chaos, and societal unrest she details these workers struggles to be paid for the work they were heroically performing. Not only were these individuals not being paid the hazard pay they were due but overt fraud was occurring. As Maxmen writes:

Yet almost immediately, the World Bank— a far larger contributor of funds— noticed signs of corruption in Sierra Leone’s health system. When they looked at the pay lists of frontline staff created by officials in the Ministry of Health, they discovered “ghostworkers”— aliases, family members, and mistakes in enumeration— all of which meant certain people might be collecting more money than they deserved.

This scenario caused the World Bank to innovate and use electronic payments directly to workers. The use of text messaging in the process led to the system becoming known as "mobile-money". Such a process stopped skimming by corrupt local officials.

I recommend this short book to all who are interested in Ebola, global health, and international funding mechanisms. That corruption exists and money vanishes before it reaches its intended target was something I knew occurred with regularity but I never really understand the mechanics of how it happens. Ms. Maxmen's work concretizes how, during what was an existential crisis caused by a parasitical virus, certain parasitical looting humans--in a nation in which individual rights and the rule of law are empty concepts--made the battle much more difficult. 

Pregnancy as an Ebola Potentiator: Trying to Understand the Liberian cluster

One of the most recent mysteries of Ebola is the recent re-establishment of the disease in Liberia, which had rid itself of the disease months earlier. This cluster of 3 infections was puzzling as the index case was a 15 year old boy who had no known contact with Ebola patients.

Further investigation revealed that the boy's mother had antibodies to the virus yet was never noted to be an Ebola case -- she likely represented the rare occurrence of a minimally symptomatic Ebola patient. Her uncle had succumbed to Ebola in July 2014 and likely passed it silently to his sister.

So what happened in the ensuing 4 months? One hypothesis is the mother became pregnant. Pregnancy is a well-known to be associated with diminished immune system function (e.g. pregnancy and severe influenza) and possibly lurking remnants of Ebola, freed from total immune surveillance, begin to stir again and reached levels sufficient to infect the boy. This asymptomatic shedding of Ebola has been reported in other pregnant women who, in most circumstances, are considered at higher risk for severe Ebola. The mother, with her antibodies and her genetics (which protected her the first time), had no outward symptoms.

When the origin of this transmission is hopefully definitively established through genetic sequencing of the viruses, it will provide much insight into the residual risk of transmission that there may be from Ebola survivors. While it is known that sexual transmission from males is possible up to 6 months from recovery, the other Ebola sanctuaries (Dr. Ian Crozier's eye, Nurse Pauline Cafferkey's central nervous system) have not yet been linked to transmission. Another important question will revolve on understanding just who has subclinical infection and who has persistent virus.

Elucidating these risks in more detail will influence how Ebola vaccination is used to protect those not just in contact with active cases, but those in contact with recovered  cases.